Pediatric Dental Health

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TOPIC

Does Day Care Spread Disease?
Children attending day care are very good at sharing a number of bacterial,
viral, and parasitic infections with each other. Day care is an ideal
environment for the spread of disease among children, because: the children move
about and interact with other, their personal hygiene is less than ideal, their
ability to control their bodily secretions and excretions is poor, and their
immune systems are not yet fully developed.

TYPES OF CHILD CARE SERVICE:

Small-family child care, which is provided in a private residence for less
than 6 unrelated children.

Large-family child care, which is provided in a private residence for 7 to
12 children.

Center child care, which is provided in a non-residential setting for 13
or more children.

Sick-child care, which is provided for mildly ill children.

WHY ARE CHILDREN ATTENDING DAY CARE SUSCEPTIBLE TO INFECTIONS?

They explore the environment with their mouths, usually drooling in the
process.

They have poor control of their secretions (saliva) and excretions
(feces).

They have frequent close contact with other infants and toddlers.

They all have direct contact with the same day care providers.

They have immature immune defense systems.

Their personal hygiene is less than ideal.

HOW IS DISEASE SPREAD IN DAY CARE FACILITIES?:

The Fecal-Oral Route: It is responsible for Escherichia coli
O157:H7 and hepatitis A infections. Note that the risk for food
contamination is higher when the person who prepares or serves the food also
diapers the children.

By Skin Contact: It is responsible for head lice and scabies infections.

The Blood, Urine, or Saliva Routes: They are responsible for
cytomegalovirus, hepatitis B and C virus, and herpes simplex virus
infections.

HOW TO PREVENT THE SPREAD OF ORAL HERPES (HSV-1) AND HEPATITIS B (HBV) IN
DAY CARE FACILITIES:

Day care providers must practice excellent personal hygiene with frequent
handwashing, using soap and water.

All shared toys must be cleansed in the dishwasher, or disinfected with a
1:64 solution of household bleach, at least once a day.

Children should not share food, drinks, eating utensils, cups, or drinking
glasses.

Children should not share toothbrushes.

PREVENTING THE SPREAD OF DISEASE IN DAY CARE:

Caregivers must wash their hands frequently with soap and water,
especially after diapering children.

Written procedures for diaper changing and handwashing should be posted
and enforced.

Caregivers must practice hygienic methods of diapering infants and
toddlers.

Caregivers must practice meticulous personal hygiene.

Caregivers must have their immunizations updated and recorded.

All children must have their immunizations updated and recorded.

Communicable diseases in the day care center need to be reported to the
health department.

Written policies should be in place for managing child and employee
illness.

Infants and toddlers should be separated to reduce infections.

Sanitation procedures must be thorough.

Food handling procedures must be strict.

Food should be handled hygienically and safely to prevent the spread of
disease. Hands should always be washed before handling food. Staff members
who change children's diapers should not prepare or serve food.

Practice hygienic procedures for child toilet use.

Toilet areas and toilet training equipment must be maintained in a
sanitary condition.

Each item of sleep equipment should only be used by a single child.

The AAP 2000 Red Book includes a chapter on day care
infections.

Children in Out-Of-Home Child Care: AAP 2000 Red Book: Report of the
Committee on Infectious Diseases. 25th ed; American Academy of Pediatrics;
2000:pp105-119.

Emergency: A Child's Tooth Has Been Knocked Out!
One of the most distressing experiences for a child is to have a permanent
front tooth knocked out. This may happen as a result of a sports mishap, a
fall inside of the home, or other trauma. Every tooth has a protective layer
surrounding the root, which is called the periodontal ligament. The
periodontal ligament is very sensitive, and will quickly dry out and die -
unless the tooth is immediately placed in a protective solution, such as
milk or saline. With every minute that the tooth is left out of the mouth to
dry, more cells in the periodontal ligament will die.

The best way to preserve a tooth which has been knocked out (avulsed) is to
put it back into its socket as quickly as possible. If that isn't possible,
the tooth should be placed into a protective solution. The goal of
reimplanting the tooth into the socket is to preserve the health of the
tooth's outer periodontal ligament. If the cells of the periodontal ligament
are allowed to die, the child will eventually loose the tooth.

FIRST AID FOR AN AVULSED (KNOCKED OUT) TOOTH:

1. Do not touch the root of the tooth. Handle the tooth by the crown only.

2. Rinse the tooth off only if there is dirt covering it.

3. Attempt to reimplant the tooth into the socket with gentle pressure,
and hold it in position.

4. If unable to reimplant the tooth, place it in a protective transport
solution, such as Hank's solution, milk, or saline. This will hydrate and
nourish the periodontal ligament cells which are still attached to the root.
A small container of Hank's Balanced Salt Solution can be purchased in
dental emergency kit form at many drug stores.

5. The tooth should not be wrapped in tissue or cloth.

6. Take the child to a dentist or hospital emergency room for evaluation
and treatment.

PROCEDURES IN THE DENTAL OFFICE OR HOSPITAL EMERGENCY ROOM:

1. Place the tooth in Hank's Balanced Salt Solution.

2. Take a medical and dental history, and perform a physical examination.
Rule out CNS injury.

3. Examine the orofacial area. Inspect the oral soft tissue for embedded
tooth fragments, lacerations, or ecchymosis. Palpate the teeth and
dentoalveolar area to check for mobility. Evaluate TMJ function.

4. If the tooth is missing, rule out aspiration or ingestion.

5. Take a maxillary occlusal radiograph, as well as a lateral anterior
radiograph of the injured area. Consider taking a panoramic radiograph to
rule out condylar or mandibular fractures.

6. Gently aspirate the injured area without entering the socket. If a clot
is present, dislodge and remove it using light saline irrigation. Do not
curette the socket.

TOOTH REIMPLANTATION GUIDELINES:

1. For A Mature Tooth With A Closed Apex: If the extraoral dry time is
<60 minutes, reimplant as soon as possible. If the extraoral dry time is
>60 minutes, soak in citric acid or curette the root; then soak in
fluoride for 10 minutes. Rinse with saline.

2. For An Immature Tooth With An Open Apex: If the extraoral dry time is
<60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the
extraoral dry time is >60 minutes, provide the same treatment as for a
closed apex.

3. Apply a functional splint for 7 to 10 days. If an alveolar fracture is
present, provide a rigid splint for 4-6 weeks.

7. Provide analgesics to control pain. For children, consider prescribing
acetaminophen and codeine (Tylenol #3) for mild to moderate pain. The dose
is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 G/day of
acetaminophen.

8. Arrange for tetanus vaccination if the wound was dirty, or if the
vaccination requires updating.

FOLLOW-UP CARE AFTER 7 TO 10 DAYS:

1. For a tooth with an open apex and extraoral dry time <60 minutes: no
endodontic treatment is initially required. Re-evaluate every 3-4 weeks for
pathosis. In case of pulp pathosis, begin an apexification procedure.>

2. For a tooth with an open apex and extraoral dry time >60 minutes:
begin an apexification procedure.

3. For a tooth with a closed apex: provide traditional endodontic
treatment and obturation.

4. Remove the splint at this 7 to 10 day treatment visit.

ENDODONTIC OBTURATION FOR AVULSED TEETH WITH CLOSED APICES:

1. For a tooth with endodontic treatment started 7 to 10 days after
avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide
paste.

2. For a tooth with radiographic signs of resorption or pathosis, or for a
tooth which had endodontic treatment started more than 14 days after the
avulsion, treat long term with a dense mix of calcium hydroxide. Obturate
when an intact lamina dura can be visualized.

A recent article in the British Dental Journal examined the
effect of various factors on the prevalence of external root resorption in
avulsed teeth. This study concluded that the major risk factors for external
root resorption were the degree of root contamination, and the extraoral dry
time.

Kinirons MJ, Gregg TA, Welbury RR, Cole BOI: Variations in the
presenting and treatment features in reimplanted permanent incisors in
children, and their effect on the prevalence of root resorption. British
Dental Journal. Sept 9, 2000. 189(5)263-266.

What Are Dental Eruption Cysts?
A dental eruption cyst is an oral soft tissue cyst which appears during
childhood, and forms around an erupting primary or permanent tooth. Eruption
cysts are not malignant.

Forty-five percent of all children experience eruption cysts. Eruption cysts
and eruption hematomas are very similar, and differ only in their color.
Both types of cysts are smooth, soft, swellings which appear over the area
where a child's tooth is about to come in. They may be as large as 1/4 inch
in diameter. They usually are clear, or may have a bluish color. Eruption
hematomas are simply eruption cysts which have a very dark color.

WHEN DO ERUPTION CYSTS APPEAR?

1. Shortly before the underlying tooth erupts into the mouth.

2. They can appear as early as 5 months of age, or as late as 12 years of
age.

WHAT CAUSES AN ERUPTION CYST?

1. An eruption cyst develops when fluid accumulates between an erupting
tooth and the overlying layer of enamel epithelium.

2. An eruption cyst is really a dentigerous cyst which appears in oral
soft tissue.

WHAT IS THE TREATMENT FOR AN ERUPTION CYST?

1. Most eruption cysts disappear spontaneously as soon as the underlying
tooth erupts into the mouth.

2. No treatment is usually needed, since most of these cysts heal within 5
weeks.

3. Giving an infant a cold teething ring may help alleviate some of the
discomfort associated with eruption cysts.

4. When a child experiences feeding problems or severe discomfort as a
result of eruption cysts, it may be necessary to have them incised or
surgically removed.

A recent article which appears in the Journal of Dentistry for
Children reports a case of a fifteen-month-old boy who experienced
multiple dental eruption cysts. The cysts were causing some feeding
problems, as well as discomfort. The problem was treated surgically by
incising the eruption cysts, and removing part of the overlying cystic
tissue.

Does Gum Disease Cause Premature Babies?
Birth weight is the most important predictor of an infant's chances of
growing and developing normally. There are approximately 250,000 premature
low-weight infants born each year in the United States. Approximately one in
10 births result in a preterm low birth weight baby.

Preterm and low birth weight babies are born before 37 weeks, and weigh less
than 2,500 grams at birth. The normal, full term, duration of a pregnancy is
40 weeks.

Preterm infants with low birth weight are a major public health concern.
Most cases of long-term childhood disability begin as low birth weight
infants. The hospital costs associated with premature babies are greater
than $5 billion annually in the U.S. The social and emotional costs
associated with premature infants are also staggering.

Researchers estimate that 18 percent of these premature births may be
related to infectious oral disease in pregnant women. Periodontal (gum)
disease may cause a sevenfold increase in the risk of delivering a premature
low birth weight baby. If periodontal disease in pregnant women were
eliminated, the number of low-weight babies could be reduced by
approximately 45,000 in the U.S.

Maternal infection has been linked to preterm birth. Actually, any infection
during pregnancy can cause a disturbance in the levels of maternal hormones
and cytokines. Oral infections, such as periodontitis, can also cause an
increase in the circulating levels of molecules such as PGE2 and TNF alpha
(a type of cytokine) .

Labor begins when there is a sudden change in the mother's internal
regulatory system. A periodontal infection will accelerate the production of
these chemical mediators, and can trigger a premature delivery. In fact, the
hormone PGE2 (prostaglandin E2) can be used to induce labor.

Pregnant women should therefore observe meticulous oral hygiene, and should
keep their normal dental checkup schedule. Maintaining good oral health
during pregnancy will help produce a healthy, happy baby.

A recent article in Periodontology 2000 reviewed the various
risk factors for preterm low birth weight. The article also described the
mechanisms by which periodontal disease in pregnant women may cause preterm
delivery.